| (a) A facility providing detoxification services shall
ensure every individual admitted to a detoxification program meets
the DSM criteria for substance intoxication or withdrawal.
(b) All detoxification programs shall ensure continuous
access to emergency medical care.
(c) The program shall have a medical director who is
a licensed physician. The medical director shall be responsible for
admission, diagnosis, medication management, and client care.
(d) The medical director or his/her designee (physician
assistant, or nurse practitioner) shall approve all medical policies,
procedures, guidelines, tools, and the medical content of all forms,
which shall include:
(1) screening instruments and procedures;
(2) protocol or standing orders for each major drug
category of abusable drugs (opiates, alcohol and other sedative-hypnotic/anxiolytics,
inhalants, stimulants, hallucinogens) that are consistent with guidelines
published by nationally recognized organizations (e.g., Substance
Abuse and Mental Health Services Administration, American Society
of Addiction Medicine, American Academy of Addiction Psychology);
(3) procedures to deal with medical emergencies;
(4) medication and monitoring procedures for pregnant
women that address effects of detoxification and medications used
on the fetus; and
(5) special consent forms for pregnant women identifying
risks inherent to mother and fetus.
(e) The medical director or his/her designee (physician
assistant, nurse practitioner) shall authorize all admissions, conduct
a face-to-face examination, to include both a history and physical
examination of each applicant for services to establish the Axis I
diagnosis, assess level of intoxication or withdrawal potential, and
determine the need for treatment and the type of treatment to be provided
to reach a placement decision.
(1) The examination shall identify potential physical
and mental health problems and/or diagnoses that warrant further assessment.
(2) The authorization and examination shall be documented
in the client record and shall contain sufficient documentation to
support the diagnoses and the placement decision. If the physician
determines an admission was not appropriate, the client shall be transferred
to an appropriate service provider.
(3) The face-to-face examination (history and physical
examination) and signed orders of admission shall occur within 24
hours of admission.
(4) The program may accept an examination completed
during the 24 hours preceding admission if it is approved by the program's
medical director or designee and includes the elements of paragraphs
(1) and (2) of this subsection. The program may not require a client
to obtain a history and physical as a condition of admission.
(5) Detoxification programs shall have a licensed vocational
nurse or registered nurse on duty for at least eight hours every
day and a physician or designee on call 24 hours a day.
(6) Detoxification programs shall ensure that detoxification
services are accessible at least 16 hours per day, seven days per
week.
(f) Providers shall develop and implement a mechanism
to ensure that all direct care staff in detoxification programs have
the knowledge, skills, abilities to provide detoxification services,
as they relate to the individual's job duties. Providers must be able
to demonstrate through documented training, credentials and/or experience
that all direct care staff are proficient in areas pertaining to detoxification,
including but not limited to areas regarding:
(1) signs of withdrawal;
(2) observation and monitoring procedures;
(3) pregnancy-related complications (if the program
admits women);
(4) complications requiring transfer;
(5) appropriate interventions; and
(6) frequently used medications including purpose,
precautions, and side effects.
(g) Residential and ambulatory (outpatient) detoxification
programs shall provide monitoring to manage the client's physical
withdrawal symptoms. Monitoring shall be conducted at a frequency
consistent with the degree of severity of the client's withdrawal
symptoms, the drug(s) from which the client is withdrawing, and/or
the level of intoxication of the client. This information will be
documented in the client's record and reflected in the client's orders.
(1) Monitoring shall include:
(A) changes in mental status;
(B) vital signs; and
(C) response of the client's symptoms to the prescribed
detoxification medications
(2) Use of instruments such as the Clinical Institute
Withdrawal Assessment-Alcohol, revised (CIWA-Ar) for alcohol and sedative
hypnotic withdrawal and the "clinician's assessment" in the Behavioral
Health Integrated Provider System (BHIPS) is recommended.
(3) More intensive monitoring is required for clients
with a history of severe withdrawal symptoms (e.g. a history of hallucinosis,
delirium tremors, seizures, uncontrolled vomiting/dehydration, psychosis,
inability to tolerate withdrawal symptoms, self harming attempts),
or the presence of current severe withdrawal symptoms and/or co-occurring
medical and psychiatric disorders.
(4) At a minimum, monitoring should be done every four
hours in residential detoxification programs for the first 72 hours
and as ordered by the medical director or designee thereafter, dependent
on the client's signs and symptoms.
(5) Medication should be available to manage withdrawal/intoxication
from all classes of abusable drugs.
(6) Medication "regimens", "protocols" or standing
orders can be used, but detoxification should be tailored to each
client's need based on vital signs and symptom severity (objective
and subjective) and noted in the client's record.
(7) Ambulatory detoxification should have clear documentation
by the physician or designee that the client's symptoms are or are
expected to be of a severity that necessitates a minimum of once a
day monitoring.
(h) In addition to the management of withdrawal and
intoxicated states, detoxification programs shall provide services,
including counseling, which are designed to:
(1) assess the client's readiness for change;
(2) offer general and individualized information on
substance abuse and dependency;
(3) enhance client motivation;
(4) engage the client in treatment; and
(5) include a detoxification plan that contains the
goals of successful and safe detoxification as well as transfer to
another intensity of treatment. At least one daily individual session
by a registered nurse, QCC or counselor intern with the client will
be conducted.
(i) Ambulatory detoxification shall not be a stand
alone service and services shall be provided in conjunction with outpatient
treatment services. When treatment services are not available in conjunction
with ambulatory detoxification services, the ambulatory detoxification
program shall arrange for them.
(j) Bunk beds shall not be used in residential detoxification
programs.
(k) In residential programs, direct care staff shall
be on duty where the clients are located 24 hours a day.
(1) During day and evening hours, at least two staff
shall be on duty for the first 12 clients, with one more staff on
duty for each additional one to 16 clients.
(2) At night, at least one staff member with detoxification
training shall be on duty for the first 12 clients with one more staff
on duty for each additional one to 16 clients.
(l) Clients who are not in withdrawal but meet the
DSM criteria for substance dependence may be admitted to detoxification
services for 72 hours for crisis stabilization.
(m) Crisis stabilization is appropriate for clients
who have diagnosed conditions that result in current emotional or
cognitive impairment in clients such that they would not be able to
participate in a structured and rigorous schedule of formal chemical
dependency treatment.
(1) The specific client signs and symptoms that meet
the DSM or other medical criteria for the disorder must be documented
in the client record.
(2) Documentation must also include what symptoms are
precluding the client from participating in treatment and the manner
in which they are to be resolved.
|
| Source Note: The provisions of this §564.902 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197 |
